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D’Silva LJ, Phongsavath T, Partington K, Pickle NT, Marschner K, Zehnbauer TP, Rossi M, Skop K, Roos PE. A gaming app developed for vestibular rehabilitation improves the accuracy of performance and engagement with exercises. Front Med (Lausanne) 2023; 10:1269874. [PMID: 38076248 PMCID: PMC10704144 DOI: 10.3389/fmed.2023.1269874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/06/2023] [Indexed: 02/12/2024] Open
Abstract
Introduction Vestibular hypofunction is associated with dizziness, imbalance, and blurred vision with head movement. Vestibular rehabilitation is the gold standard recommendation to decrease symptoms and improve postural stability. The Clinical Practice Guidelines for vestibular hypofunction suggest home exercises 3-5 times daily, but patient adherence is a problem, with compliance rates often below 50%. Methods An app was developed to increase engagement with home exercises by providing exercises as games. This study compared the accuracy of exercise performance in a one-time session using the app versus no-app and gathered participant feedback on using the app for vestibulo-ocular reflex (VOR) and balance exercises. The app was tested with 40 adults (20 women), mean age of 67 ± 5.7 years, with symptomatic unilateral or bilateral vestibular hypofunction. Participants completed VOR exercises in pitch and yaw planes, weight-shift, and single-leg balance exercises using an inertial motion unit to move the character on the tablet screen. Participants were randomly assigned to begin the exercises with or without the app. Results Results show that during VOR exercises, participants achieved the prescribed frequency of head motion for the yaw plane (p ≤ 0.001) and reduced variability of head movement frequency in both the yaw (p ≤ 0.001) and pitch plane (p ≤ 0.001) in the app compared to the no-app condition. During weight-shifting exercises, a larger range of body motion was noted in the anteroposterior and mediolateral directions in the app compared to the no-app condition (p < 0.05). During single-leg balance exercises, pelvic motion was lower in the app versus no-app condition (p = 0.02). Participants modified their exercise performance and corrected their mistakes to a greater extent when they used the app during the VOR exercises. Participants agreed that they felt motivated while playing the games (97%) and felt motivated by the trophies (92%). They agreed that the app would help them perform the exercises at home (95%), improve their rehab performance (95%) and that it was fun to do the exercises using the app (93%). Discussion The results of this study show that technology that is interactive and provides feedback can be used to increase accuracy and engagement with exercises.
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Affiliation(s)
- Linda J. D’Silva
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas, MO, United States
| | - Tarah Phongsavath
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas, MO, United States
| | - Kelly Partington
- Department of Physical Therapy, Rehabilitation Science, and Athletic Training, University of Kansas Medical Center, Kansas, MO, United States
| | - Nathan T. Pickle
- Biomedical, Energy and Materials, CFD Research Corporation, Huntsville, AL, United States
| | - Katherine Marschner
- Biomedical, Energy and Materials, CFD Research Corporation, Huntsville, AL, United States
| | - Timothy P. Zehnbauer
- Biomedical, Energy and Materials, CFD Research Corporation, Huntsville, AL, United States
| | - Michael Rossi
- Biomedical, Energy and Materials, CFD Research Corporation, Huntsville, AL, United States
| | - Karen Skop
- Physical Medicine and Rehabilitation Services, Department of Physical Therapy, James A. Haley Veterans’ Hospital, Tampa, FL, United States
- School of Physical Therapy, Morsani College of Medicine, University of South Florida, Tampa, FL, United States
| | - Paulien E. Roos
- Biomedical, Energy and Materials, CFD Research Corporation, Huntsville, AL, United States
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Raciti FM, Morales Y, Snapp HA, Rajguru SM. A reliable and reproducible protocol for sound-evoked vestibular myogenic potentials in rattus norvegicus. Front Integr Neurosci 2023; 17:1236642. [PMID: 37731913 PMCID: PMC10508189 DOI: 10.3389/fnint.2023.1236642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/21/2023] [Indexed: 09/22/2023] Open
Abstract
Introduction Cervical vestibular evoked myogenic potentials (cVEMPs) provide an objective measure of the integrity of the sacculo-collic pathway leading to their widespread use as a clinical tool in the diagnostic vestibular test battery. Though the application of cVEMPs in preclinical models to assess vestibular function, as performed in relevant clinical populations, remains limited. The present study aimed to establish a rodent model of cVEMP with standardized methods and protocols, examine the neural basis of the responses, and characterize and validate important features for interpretation and assessment of vestibular function. Methods We compared air-conducted sound (ACS)-evoked VEMPs from the sternocleidomastoid muscles in naïve Brown Norway rats. A custom setup facilitated repeatable and reliable measurements which were carried out at multiple intensities with ACS between 1 and 16 kHz and over 7 days. The myogenic potentials were identified by the presence of a positive (P1)-negative (N1) waveform at 3-5 ms from the stimulus onset. Threshold, amplitude, and latency were compared with intensity- and frequency-matched responses within and between animals. Results cVEMP responses were repeatedly evoked with stimulus intensities between 50-100 dB SPL with excellent test-retest reliability and across multiple measurements over 7 days for all frequencies tested. Suprathreshold, cVEMP responses at 90 dB SPL for 6-10 kHz stimuli demonstrated significantly larger amplitudes (p < 0.01) and shorter latencies (p < 0.001) compared to cVEMP responses for 1-4 kHz stimuli. Latency of cVEMP showed sex-dependent variability, but no significant differences in threshold or amplitude between males and females was observed. Discussion The results provide a replicable and reliable setup, test protocol, and comprehensive characterization of cVEMP responses in a preclinical model which can be used in future studies to elucidate pathophysiological characteristics of vestibular dysfunctions or test efficacy of therapeutics.
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Affiliation(s)
- Federica M. Raciti
- Department of Otolaryngology, University of Miami, Miami, FL, United States
- Department of Biomedical Engineering, University of Miami, Miami, FL, United States
| | - Yasniary Morales
- Department of Otolaryngology, University of Miami, Miami, FL, United States
- Department of Biomedical Engineering, University of Miami, Miami, FL, United States
| | - Hillary A. Snapp
- Department of Otolaryngology, University of Miami, Miami, FL, United States
- Department of Biomedical Engineering, University of Miami, Miami, FL, United States
| | - Suhrud M. Rajguru
- Department of Otolaryngology, University of Miami, Miami, FL, United States
- Department of Biomedical Engineering, University of Miami, Miami, FL, United States
- Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL, United States
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Casani AP, Gufoni M. Recurring benign paroxysmal positional vertigo after successful canalith repositioning manoeuvers. Acta Otorhinolaryngol Ital 2023; 43:S61-S66. [PMID: 37698102 PMCID: PMC10159632 DOI: 10.14639/0392-100x-suppl.1-43-2023-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 01/08/2023] [Indexed: 09/13/2023]
Abstract
Benign baroxysmal positional vertigo (BPPV) represents the most common peripheral vestibular dysfunction encountered in clinical practice. Although canalith repositioning procedures (CRPs) are a relatively successful treatment for BPPV, many patients suffer from recurrences. Several studies have demonstrated that various pathological conditions (diabetes, hypertension, endolymphatic hydrops, low vitamin D levels) as well as delayed BPPV treatment using CRP, multiple canal involvement may be associated with recurrence of BPPV. We evaluated the history of 1,428 patients (558 males and 870 females, age range 10-92 years) suffering from BPPV. Of 1,428 cases, 820 (77%) did not relapse in the following 20 years. Mean age and gender did not differ significantly between groups with and without recurrence. Regarding risk factors for BPPV recurrence, age, female gender, migraine, hypertension, diabetes mellitus, hyperlipidaemia, osteoporosis, vascular diseases, and vitamin D deficiency may be associated with recurrent BPPV and should be kept in mind. Osteoporosis, vitamin D deficiency as well as thyroid dysfunction should be evaluated in postmenopausal women. Treatment of these comorbidities may help to reduce the risk of BPPV recurrence.
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Affiliation(s)
- Augusto Pietro Casani
- Department of Medicine and Surgery, ENT Section, Pisa University Hospital, Pisa, Italy
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Alharbi AA, Alshammari ME, Albalwi AA, Ramadan MM, Alsharif DS, Hafiz AE. Dizziness in Saudi Arabia: An epidemiologic study. Front Neurol 2023; 14:1040231. [PMID: 37090980 PMCID: PMC10117996 DOI: 10.3389/fneur.2023.1040231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/15/2023] [Indexed: 04/25/2023] Open
Abstract
Introduction Dizziness is one of the most common and recurring complaints in adults presenting at the clinic. However, its prevalence in the population of the Kingdom of Saudi Arabia remains unclear. We aimed to examine the prevalence and correlates of dizziness in a large sample of the Saudi population. Methods In this is cross-sectional study, we used an electronic survey, which was completed by 1.478 respondents, with a response rate of 84% across five regions of Saudi Arabia. The online survey was launched on the Qualtrics website and distributed via social media channels to obtain heterogeneous responses. The study included adults aged ≥18 years who resided in Saudi Arabia during data collection. We used t-test and chi-square test for descriptive analysis and multiple logistic regression model to assess prevalence and predictors of dizziness. Results More than half of the participants were aged between 26 years and 45 years (58.66%). Of the participants, 42.97% reported having dizziness at the time of taking the survey. Women were less likely than men to report dizziness (OR = 0.65; CI, 0.49, 0.87; p = 0.003). A description of the type of dizziness by age revealed that vertigo slightly decreased with age. Unclear vision with movement or blurry vision was common in young adults, whereas imbalance was common in older adults. A multiple regression model adjusted for demographic characteristics revealed a statistically significant association between dizziness and age group. Participants in the age group of 46-55 years were 1.83 times more likely to report dizziness compared to those aged >65 years (odds ratio = 1.83; confidence interval, 0.62, 5.41; p = 0.0009). Discussion Dizziness is a common complaint in Saudi Arabia. Future studies should elucidate the risk factors for and mechanisms of dizziness to help prevent falls and reduced quality of life.
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Affiliation(s)
- Ahmad A. Alharbi
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia
| | - Maryam E. Alshammari
- Department of Cochlear Implant, Hafar Albatin Central Hospital, Hafar Albatin, Saudi Arabia
| | - Abdulaziz A. Albalwi
- Department of Physical Therapy, Faculty of Applied Medical Sciences, University of Tabuk, Tabuk, Saudi Arabia
| | - Majed M. Ramadan
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences C9F6+JRH, King Abdul Aziz Medical City, Jeddah, Saudi Arabia
- *Correspondence: Majed M. Ramadan,
| | - Doaa S. Alsharif
- Department of Medical Rehabilitation, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Ammar E. Hafiz
- Department of Physical Therapy, School of Medical Rehabilitation Science, King Abdulaziz University, Kingdom of Saudi Arabia, Jeddah, Saudi Arabia
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Barreto RG, Yacovino DA, Cherchi M, Nader SN, Teixeira LJ, Silva DAD, Verdecchia DH. The Role of the Smartphone in the Diagnosis of Vestibular Hypofunction: A Clinical Strategy for Teleconsultation during the COVID-19 Pandemic and Beyond. Int Arch Otorhinolaryngol 2021; 25:e602-e609. [PMID: 34777592 PMCID: PMC8580156 DOI: 10.1055/s-0041-1736340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023] Open
Abstract
Introduction Vestibular disorders (VDs) are highly prevalent in primary care. Although in general they comprise conditions that are not life-threatening, they are associated with significant functional and physical disability. However, the current coronavirus disease 2019 (COVID-19) pandemic has imposed limitations on the standard treatment of benign conditions, including VDs. In this context, other resources may aid in the diagnosis and management of patients with VDs. It is well known that teleconsultation and teletreatment are both safe and effective alternatives to manage a variety of conditions, and we maintain that VDs should be among these. Objective To develop a preliminary model of clinical guidelines for the evaluation by teleconsultation of patients with suspected diagnosis of vestibular hypofunction during the COVID-19 pandemic and beyond. Methods A bibliographic review of the diagnostic feasibility in VDs by teleconsultation was carried out in the LILACS, SciELO, MEDLINE, and PubMed databases; books and specialized websites were also consulted. The legal, regulatory, and technical issues involving digital consultations were reviewed. Results We found 6 field studies published between 1990 and 2020 in which the efficiency of teleconsultations was observed in the contexts of epidemics and environmental disorders and disadvantageous geographical conditions. After reviewing them, we proposed a strategy to examine and address vestibular complaints related to vestibular hypofunction. Conclusion The creation of a digital vestibular management algorithm for the identification, counseling, initial intervention, monitoring and targeting of people with possible vestibular hypofunction seems to be feasible, and it will provide a reasonable alternative to in-person evaluations during the COVID-19 pandemic and beyond.
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Affiliation(s)
- Renato Gonzaga Barreto
- Neurotology and Vestibular Rehabilitation, Clínica de Neurologia e Psiquiatria, São Paulo, SP, Brazil
| | - Darío Andrés Yacovino
- Otovestibular Section, Neurology Department, Hospital Dr. César Milstein, Buenos Aires, Argentina
- Neurotology and Vestibular Rehabilitation, Laboratorio de Memoria y Equilibrio, Buenos Aires, Argentina
| | - Marcello Cherchi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Neurotology, Chicago Dizziness and Hearing, Chicago, IL, USA
| | - Saulo Nardy Nader
- Neurotology and Vestibular Rehabilitation, Clínica de Neurologia e Psiquiatria, São Paulo, SP, Brazil
| | | | | | - Daniel Hector Verdecchia
- Kinesiology and Physiatry Course, Department of Health Sciences, Universidad Nacional de La Matanza, Buenos Aires, Argentina
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Figtree WVC, Menant JC, Chau AT, Hübner PP, Lord SR, Migliaccio AA. Prevalence of Vestibular Disorders in Independent People Over 50 That Experience Dizziness. Front Neurol 2021; 12:658053. [PMID: 34093406 PMCID: PMC8176523 DOI: 10.3389/fneur.2021.658053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
People aged over 50 are the most likely to present to a physician for dizziness. It is important to identify the main cause of dizziness in order to develop the best treatment approach. Our goal was to determine the prevalence of benign paroxysmal positional vertigo (BPPV), and peripheral and central vestibular function in people that had experienced dizziness within the past year aged over 50. One hundred and ninety three community-dwelling participants aged 51–92 (68 ± 8.7 years; 117 females) were tested using the clinical and video head impulse test (cHIT and vHIT) to test high-frequency vestibular organ function; the head thrust dynamic visual acuity (htDVA) test to test high-frequency visual-stability; the dizziness handicap inventory (DHI) to measure the impact of dizziness; as well as sinusoidal and unidirectional rotational chair testing to test low- to mid-frequency peripheral and central vestibular function. From these assessments we computed the following measures: HIT gain; htDVA score; DHI score; sinusoidal (whole-body; 0.1–2 Hz with 30°/s peak-velocity) vestibulo-ocular reflex (VOR) gain and phase; transient (whole-body, 150°/s2 acceleration to 50°/s constant velocity) VOR gain and time constant; optokinetic nystagmus (OKN) gain and time constant (whole-body, 50°/s constant velocity rotation). Our study showed that BPPV, and peripheral or central vestibular hypofunction were present in 34% of participants, suggesting a vestibular cause to their dizziness. Over half (57%) of these with a likely vestibular cause had BPPV, which is more than twice the percentage reported in other dizzy clinic studies. Our findings suggest that the physical DHI score and VOR time constant were best at detecting those with non-BPPV vestibular loss, but should always be used in conjunction with cHIT or vHIT, and that the htDVA score and vHIT gain were best at detecting differences between ipsilesional and contralesional sides.
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Affiliation(s)
- William V C Figtree
- Balance and Vision Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Jasmine C Menant
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Allan T Chau
- Balance and Vision Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Patrick P Hübner
- Balance and Vision Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Stephen R Lord
- Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Americo A Migliaccio
- Balance and Vision Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,School of Biomedical Sciences and Pharmacy, University of Newcastle, Newcastle, NSW, Australia
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Rinaudo CN, Schubert MC, Cremer PD, Figtree WVC, Todd CJ, Migliaccio AA. Once-Daily Incremental Vestibular-Ocular Reflex Adaptation Training in Patients With Chronic Peripheral Vestibular Hypofunction: A 1-Week Randomized Controlled Study. J Neurol Phys Ther 2021; 45:87-100. [PMID: 33675600 DOI: 10.1097/NPT.0000000000000348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE This was a double-blinded randomized controlled study to investigate the effects of once-daily incremental vestibulo-ocular reflex (VOR) training over 1 week in people with chronic peripheral vestibular hypofunction. METHODS A total of 24 patients with peripheral vestibular hypofunction were randomly assigned to intervention (n = 13) or control (n = 11) groups. Training consisted of either x1 (control) or incremental VOR adaptation exercises, delivered once daily for 15 minutes over 4 days in 1 week. Primary outcome: VOR gain with video-oculography. Secondary outcomes: Compensatory saccades measured using scleral search coils, dynamic visual acuity, static balance, gait, and subjective symptoms. Between-group differences were analyzed with a linear mixed-model with repeated measures. RESULTS There was a difference in the VOR gain increase between groups (P < 0.05). The incremental training group gain increased during active (13.4% ± 16.3%) and passive (12.1% ± 19.9%) head impulse testing (P < 0.02), whereas it did not for the control group (P = 0.59). The control group had reduced compensatory saccade latency (P < 0.02). Both groups had similarly improved dynamic visual acuity scores (P < 0.05). Both groups had improved dynamic gait index scores (P < 0.002); however, only the incremental group had improved scores for the 2 walks involving head oscillations at approximately 2 Hz (horizontal: P < 0.05; vertical: P < 0.02), increased gait speed (P < 0.02), and step length (P < 0.01) during normal gait, and improved total Dizziness Handicap Inventory (P < 0.05). CONCLUSIONS Our results suggest incremental VOR adaptation significantly improves gain, gait with head rotation, balance during gait, and symptoms in patients with chronic peripheral vestibular hypofunction more so than conventional x1 gaze-stabilizing exercises.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A336).
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Li S, Wang Z, Liu Y, Cao J, Zheng H, Jing Y, Han L, Ma X, Xia R, Yu L. Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis. Ear Nose Throat J 2020; 101:NP112-NP134. [PMID: 32776833 DOI: 10.1177/0145561320943362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Benign paroxysmal positional vertigo (BPPV) has a high recurrence rate, but the risk factor-associated recurrence are elusive. METHODS Searches were performed in PubMed, Embase, Cochrane library, Web of science, Chinese National Knowledge Infrastructure, and Sino Med up to November 3, 2019. The effect size was analyzed by odds ratio and 95% CI. Data from eligible studies were meta-analyzed using Stata version 15.0. RESULTS Our search resulted in a total of 4076 hits. Twenty-four outcomes of sixty articles were included in the meta-analysis. Risk factors for the recurrence of BPPV included female gender, age (≥65years), hyperlipidemia, diabetes, hypertension, migraine, cervical spondylosis, osteopenia/osteoporosis, head trauma, otitis media, abnormal vestibular evoked myogenic potential, and long use of computers. No significant differences were found in side, type of the involved semicircular canals, smoking, alcohol consumption, stroke, ear surgery, duration of vertigo before treatment, the times of repositioning, Meniere disease, sleep disorders, hypercholesterolemia, and 25-hydroxy vitamin D. CONCLUSION These findings strengthen clinical awareness of early warning to identify patients with potential relapse risk of BPPV and clinicians should counsel patients regarding the importance of follow-up after diagnosis of BPPV.
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Affiliation(s)
- Shichang Li
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Zijing Wang
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Yan Liu
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Jie Cao
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Hongwei Zheng
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Yuanyuan Jing
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Lin Han
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Xin Ma
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Ruiming Xia
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
| | - Lisheng Yu
- Department of Otorhinolaryngology Head and neck surgery, 71185Peking University People's Hospital, Beijing, China
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Abstract
OBJECTIVES Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV. STUDY DESIGN Retrospective study. SETTING Tertiary referral academic center. PATIENTS The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included. MAIN OUTCOME MEASURES Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM). RESULTS Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM. CONCLUSION The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.
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Wolf J, Sattel H, Limburg K, Lahmann C. From illness perceptions to illness reality? Perceived consequences and emotional representations relate to handicap in patients with vertigo and dizziness. J Psychosom Res 2020; 130:109934. [PMID: 31972479 DOI: 10.1016/j.jpsychores.2020.109934] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 01/11/2020] [Accepted: 01/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Vertigo and dizziness (VD) are frequent symptoms that can occur due to various structural pathologies or due to functional impairment. Independent of their aetiology, the symptoms are often associated with physical and psychological burden which manifests in severe handicap in more than half of the patients. It is suggested that illness perceptions, the patients' cognitive and emotional concept of their disease, most likely impact the degree of handicap. For patients with VD, however, this relation of illness perceptions and handicap is so far not well understood. This study aimed to investigate the relation of illness perceptions and handicap for patients with VD. METHODS In a cross-sectional study design, n = 419 patients with VD were examined (53.7% female, age 53.5 ± 15.5 years). Participants underwent neurological and psychiatric examinations as well as a comprehensive assessment using self-report questionnaires. RESULTS Illness perceptions, specifically perceived consequences and emotional representations showed a moderate correlation with VD related handicap (r(419) = 0.62, p < .001). Our regression model including symptom severity, psychiatric comorbidity, and aspects of cognitive and emotional illness perceptions accounted for 52% of the variance in VD related handicap. In a moderation analysis, this relation did not differ significantly in patients with functional VD symptoms. CONCLUSION Findings of the present study provide evidence for the relevance of illness perceptions to handicap in patients with VD symptoms.
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Affiliation(s)
- Johannes Wolf
- Department of Psychosomatic Medicine and Psychotherapy, Albert-Ludwigs-Universität Freiburg, Hauptstraße 8, 79104 Freiburg, Germany.
| | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Karina Limburg
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, Albert-Ludwigs-Universität Freiburg, Hauptstraße 8, 79104 Freiburg, Germany
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Yeo SS, Kwon JW, Cho IH. Associations between Age-Related Changes in the Core Vestibular Projection Pathway and Balance Ability: A Diffusion Tensor Imaging Study. Behav Neurol 2020; 2020:2825108. [PMID: 32104515 DOI: 10.1155/2020/2825108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 02/06/2023] Open
Abstract
Objective We investigated the changes of the vestibulospinal tract (VST) and parietoinsular vestibular cortex (PIVC) using diffusion tensor imaging (DTI) and relation to balance between old and young healthy adults. Methods This study recruited eleven old adults (6 males, 5 females; mean age 63.36 ± 4.25 years) and 12 young adults (7 males, 5 females; mean age 28.42 ± 4.40 years). The lateral and medial VST and PIVC were reconstructed using DTI. Fractional anisotropy (FA), mean diffusivity (MD), and tract volume were measured. The six-minute walk test (6-MWT), the timed up and go test (TUG), and the Berg balance scale (BBS) were conducted. Spatiotemporal parameters during tandem gait and values of sway during one-leg standing using the wearable sensors were measured. All parameters between two groups were analyzed by the Mann-Whitney U test and independent t-test. Results Statistically significant decrease in old adults was detected in the tract volume of lateral (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (p = 0.005) and medial VST (. Conclusion The results suggested that there was a relationship between DTI parameters in the vestibular neural pathway and balance according to aging.
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Parker IG, Hartel G, Paratz J, Choy NL, Rahmann A. A Systematic Review of the Reported Proportions of Diagnoses for Dizziness and Vertigo. Otol Neurotol 2019; 40:6-15. [PMID: 30439765 DOI: 10.1097/MAO.0000000000002044] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To determine the typical proportions of diagnoses for patients presenting with dizziness or vertigo based on clinical speciality and to assess the change in proportions of diagnoses over time. DATA SOURCES Following PRISMA guidelines, systematic searches of PubMed and CINAHL databases and follow-up reference searches were performed for articles published in English up to October 2016. STUDY SELECTION Analysis of searches yielded 42 studies meeting the criteria of case series of adult patients with dizziness and/or vertigo presenting to general practice, emergency departments or specialist outpatient clinics. DATA EXTRACTION Data comprising demographics, diagnostic cases, and the total number of cases were recorded and independently tested, followed by a risk of bias analysis. DATA SYNTHESIS Sample size weighted proportions expressed as percentages with confidence intervals were calculated and compared using χ analysis and a reference proportion formed by the combination of Ear Nose and Throat and Neurotology case series published between 2010 and 2016. Analysis of diagnostic trends over time used Poisson regression with consideration for overdispersion. CONCLUSIONS This systematic review of case series demonstrated significant differences in the proportions of diagnoses for patients presenting with dizziness or vertigo, depending on the specialty making the diagnosis. ENT proportions were dominated by BPPV, Psychogenic and Menière's disease diagnostic categories, whereas emergency proportions were dominated by Other, Cardiac, and Neurological categories. Analysis of case series proportions over time revealed increases in diagnoses such as Benign Paroxysmal Positional Vertigo and Vestibular Migraine, and a corresponding decrease in the diagnoses of Menière's disease.
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Rinaudo CN, Schubert MC, Cremer PD, Figtree WVC, Todd CJ, Migliaccio AA. Improved Oculomotor Physiology and Behavior After Unilateral Incremental Adaptation Training in a Person With Chronic Vestibular Hypofunction: A Case Report. Phys Ther 2019; 99:1326-1333. [PMID: 31197314 DOI: 10.1093/ptj/pzz083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 02/20/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND PURPOSE Traditional vestibular rehabilitation therapies are effective in reducing vestibular hypofunction symptoms, but changes to the vestibulo-ocular reflex (VOR) are minimal. This controlled case report describes an increase in VOR after 6 months of incremental VOR adaptation (IVA) training in a person with chronic unilateral vestibular hypofunction. CASE DESCRIPTION The participant was a 58-year-old female with a confirmed (Neurologist P.D.C.) left vestibular lesion stable for 2 years prior to entering a clinical trial examining the effects of daily IVA training. She was evaluated monthly for self-reported symptoms (dizziness handicap inventory), VOR function (video head impulse test), and VOR behavior (Dynamic Visual Acuity test). Intervention consisted of 6 months of 15 minutes per day unassisted training using the IVA training regime with a device developed in our laboratory. The take-home device enables the VOR response to gradually normalize on the ipsilesional side via visual-vestibular mismatch training. The intervention was followed by a 6-month wash-out and 3-month control period. The control condition used the same training device set to function like standard VOR training indistinguishable to the participant. OUTCOMES After the intervention, ipsilesional VOR function improved substantially. The VOR adapted both via a 52% increase in slow-phase response and via 43% earlier onset compensatory saccades for passive head movements. In addition, the participant reported fewer symptoms and increased participation in sports and daily activities. DISCUSSION Here, a participant with chronic vestibular hypofunction showing improved oculomotor performance atypical for traditional vestibular rehabilitation therapies, subsequent to using the newly developed IVA technique, is presented. It is the first time to our knowledge an improvement of this magnitude has been demonstrated as well as sustained over an extended period of time.
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Affiliation(s)
- Carlo N Rinaudo
- MChiro, Balance and Vision Laboratory, Neuroscience Research Australia, Sydney, NSW, Australia
| | - Michael C Schubert
- Department of Otolaryngology-Head and Neck Surgery, Laboratory of Vestibular Neuro-Adaptation, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Phillip D Cremer
- Balance and Vision Laboratory, Neuroscience Research Australia, and Royal North Shore Hospital, Sydney, Australia
| | - William V C Figtree
- Balance and Vision Laboratory, Neuroscience Research Australia, and University of New South Wales
| | - Christopher J Todd
- Balance and Vision Laboratory, Neuroscience Research Australia, and University of New South Wales
| | - Americo A Migliaccio
- Balance and Vision Laboratory, Neuroscience Research Australia, Cnr Barker Street & Easy Street, Randwick NSW 2031, Sydney, Australia
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Abstract
BACKGROUND In the present study, we investigated the localization of otopetrin-2-a member of the otopetrin family that encodes proton-selective ion channels-in the human macula utricle using immunohistochemistry. METHODS Macula utricle were acquired at surgery from patients who required transmastoid labyrinthectomy for intractable vertigo due to Meniere's disease (MD; n = 3) and/or vestibular drops attacks (VDA; n = 2) and from temporal bones (n = 2) acquired at autopsy from individuals with no balance disorders. Immunofluorescence staining with otopetrin-2 (rabbit affinity purified polyclonal antibody) and GFAP (mouse monoclonal antibody) to identify vestibular supporting cells was made in formalin fixed cryostat sections or whole microdissected utricle (for flat mount preparations). Secondary antibodies against rabbit and mouse were used for the identification of both proteins. Digital fluorescent images were obtained using a high-resolution laser confocal microscope. RESULTS Using cryostat sections and flat mount preparations otopetrin-2 immunofluorescence was seen as punctated signal throughout the supporting cells cytoplasm. GFAP immunofluorescence was present in the supporting cell cytoplasm. The distribution of otopetrin-2 was similar in the macula utricle obtained from MD, VDA, or autopsy normative patients. CONCLUSIONS Otopetrin-2 was localized in supporting cells in a similar fashion that otopetrin-1 previously reported in the mouse macula utricle. The differential expression of otopetrin-2 in the supporting cells of the human macula utricle suggest an important role in the vestibular sensory periphery homeostasis and otolith maintenance.
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Affiliation(s)
- Ivan A. Lopez
- Department of Head & Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Gail Ishiyama
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dora Acuna
- Department of Head & Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Akira Ishiyama
- Department of Head & Neck Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Kuehn E, Perez-Lopez MB, Diersch N, Döhler J, Wolbers T, Riemer M. Embodiment in the aging mind. Neurosci Biobehav Rev 2018; 86:207-225. [DOI: 10.1016/j.neubiorev.2017.11.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 12/24/2022]
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Yeo SC, Ahn SK, Lee HJ, Cho HJ, Kim SW, Woo SH, Jeon SY, Joo YH, Hur DG, Park JJ. Idiopathic benign paroxysmal positional vertigo in the elderly: a long-term follow-up study. Aging Clin Exp Res 2018; 30:153-159. [PMID: 28429295 DOI: 10.1007/s40520-017-0763-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 04/13/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral-type vertigo in the elderly. While some studies have investigated BPPV among the elderly, no study has focused on the isolated idiopathic BPPV (iBPPV) in the elderly. AIMS To investigate the clinical features and recurrence rate in elderly patients diagnosed with iBPPV. METHODS The authors prospectively reviewed the medical records of 627 patients diagnosed with BPPV, and a total of 370 patients fulfilled the inclusion criteria. The subjects were divided into two groups by age (experimental group ≥65 years and control group 17-64 years), and the gender, numbers of canalith reposition maneuver (CRM) for successful treatment, time elapsed from onset of symptoms to clinic visit, the affected semicircular canal, and the 1- and 5-year recurrence proportion were analyzed. RESULTS The gender, numbers of CRM for successful treatment, affected semicircular canal, and the 1- and 5-year recurrence proportion showed no statistically significant difference between two groups (p > 0.05). The only exception was the experimental group which took a longer duration from manifestation of symptoms to hospital visit than control group (student's t test, p = 0.021). DISCUSSION Several previous studies report that the elderly with iBPPV shows more protracted clinical course and much higher recurrence rate than younger adult. Unlike those reports, our study showed no significant differences about the clinical features and recurrence rate between age groups. CONCLUSION The elderly with iBPPV could be treated as effective as general population.
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Affiliation(s)
- Seong-Chul Yeo
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
| | - Seong-Ki Ahn
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea.
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea.
| | - Ho Joong Lee
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
| | - Hyun-Jin Cho
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Sang-Wook Kim
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Seung Hoon Woo
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Sea-Yuong Jeon
- Department of Otolaryngology, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, 90 Chilam-dong, Jinju, 660-702, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Yeon-Hee Joo
- Department of Otolaryngology, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Dong Gu Hur
- Department of Otolaryngology, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
| | - Jung Je Park
- Department of Otolaryngology, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Republic of Korea
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Bayat A, Saki N. Effects of Vestibular Rehabilitation Interventions in the Elderly with Chronic Unilateral Vestibular Hypofunction. Iran J Otorhinolaryngol 2017; 29:183-188. [PMID: 28819615 PMCID: PMC5554808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Although vestibular rehabilitation therapy (VRT) methods are relatively popular in treating patients with body balance deficits of vestibular origin, only limited studies have been conducted into customized exercises for unilateral vestibular hypofunction (UVH). Furthermore, very little evidence is available on the outcomes of VRT in the elderly population with chronic UVH. MATERIALS AND METHODS A total of 21 patients, aged 61 to 74 years, with UVH participated in this study. The dizziness handicap inventory (DHI) was performed immediately before, and 2 and 8 weeks after treatment. RESULTS All patients showed a reduction in DHI scores during the study. The average decrease in DHI score was 25.98 points after 2 weeks' intervention (P<0.001) and 32.54 points at the end of the study. This improvement was observed in all DHI subscores, and was most profound in the functional aspect. The correlation between the degree of final recovery and canal paresis was not significant (P>0.05). There were no relationships between the scores and gender. CONCLUSION Our study demonstrates that VRT is an effective method for the management of elderly patients with UVH, and shows maximal effect on functional aspects.
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Affiliation(s)
- Arash Bayat
- Musculoskletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Nader Saki
- Hearing Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Corresponding Author: Hearing Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: (+98) 916 118 7397, E-mail:
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Menant JC, Migliaccio AA, Hicks C, Lo J, Meinrath D, Ratanapongleka M, Turner J, Sturnieks DL, Delbaere K, Titov N, McVeigh C, Close JCT, Lord SR. Tailored multifactorial intervention to improve dizziness symptoms and quality of life, balance and gait in dizziness sufferers aged over 50 years: protocol for a randomised controlled trial. BMC Geriatr 2017; 17:56. [PMID: 28202037 PMCID: PMC5312521 DOI: 10.1186/s12877-017-0450-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/11/2017] [Indexed: 11/24/2022] Open
Abstract
Background Dizziness is a frequently reported symptom in older people that can markedly impair quality of life. This manuscript presents the protocol for a randomised controlled trial, which has the main objective of determining the impact of comprehensive assessment followed by a tailored multifaceted intervention in reducing dizziness episodes and symptoms, improving associated impairments to balance and gait and enhancing quality of life in older people with self-reported significant dizziness. Methods Three hundred people aged 50 years or older, reporting significant dizziness in the past year will be recruited to participate in the trial. Participants allocated to the intervention group will receive a tailored, multifaceted intervention aimed at treating their dizziness symptoms over a 6 month trial period. Control participants will receive usual care. The primary outcome measures will be the frequency and duration of dizziness episodes, dizziness symptoms assessed with the Dizziness Handicap Inventory, choice-stepping reaction time and step time variability. Secondary outcomes will include health-related quality of life measures, depression and anxiety symptoms, concern about falling, balance and risk of falls assessed with the physiological fall risk assessment. Analyses will be by intention-to-treat. Discussion The study will determine the effectiveness of comprehensive assessment, combined with a tailored, multifaceted intervention on dizziness episodes and symptoms, balance and gait control and quality of life in older people experiencing dizziness. Clinical implications will be evident for the older population for the diagnosis and treatment of dizziness. Trial registration The study is registered with the Australia New Zealand Clinical Trials Registry ACTRN12612000379819.
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Affiliation(s)
- Jasmine C Menant
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia.,School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Americo A Migliaccio
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Cameron Hicks
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Joanne Lo
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Daniela Meinrath
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia.,School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Mayna Ratanapongleka
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Jessica Turner
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Daina L Sturnieks
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia
| | - Kim Delbaere
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia.,School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia
| | - Nickolai Titov
- Department of Psychology, Macquarie University, Sydney, Australia
| | | | - Jacqueline C T Close
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia.,Prince of Wales Clinical School, Sydney, NSW, Australia
| | - Stephen R Lord
- Neuroscience Research Australia, University of New South Wales, Sydney, Australia. .,School of Public Health & Community Medicine, University of New South Wales, Sydney, Australia.
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